NUTRITIONAL ANTHROPOMETRIC SURVEY CHILDREN UNDER FIVE YEARS OLD

FINAL REPORT

MVOLO PAYAM, MVOLO COUNTY, WESTERN EQUATORIA

August 24th – September 9th, 2005

Joyce Mukiri – Nutritionist-ACF-USA Joseph Ngángá - Nutritionist-ACF-USA

“We’re together against poverty”

AGENCY FOR DEVELOPM

ENT

SUDA

NESE VOLUNTARY

SUVAD

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Deborah Morris - Nutrition Survey Program Officer-ACF-USA Victoria James Yar-SUVAD William Deng Deng-SUVAD

TABLE OF CONTENTS

ACKNOWLEDGEMENTS...................................................................................................................... 4 EXECUTIVE SUMMARY......................................................................................................................... 5 RESULTS OF ANTHROPOMETRIC SURVEY................................ERROR! BOOKMARK NOT DEFINED. INTRODUCTION.................................................................................................................................... 8 METHODOLOGY.................................................................................................................................. 8 1. Type of survey and sample size ...................................................................................................... 8 2. Sampling methodology .................................................................................................................... 9 3. Data collection.................................................................................................................................... 9 4. Indicators, guidelines and formulas used .................................................................................... 9 4.1. Acute Malnutrition .............................................................................................................................. 9 4.2. Mortality ............................................................................................................................................... 10 5. Field work............................................................................................................................................. 11 6. Data analysis ...................................................................................................................................... 11 RESULTS OF QUALITATIVE ASSESSMENT...........................................................................................11 1. Internally displaced persons (idps) and returnees population ............................................. 11 2. Food security ....................................................................................................................................... 12 3. Feeding and childcare practices ................................................................................................. 13 4. Health .................................................................................................................................................... 13 6. Education ............................................................................................................................................. 14 7. Agencies intervening in the area .................................................................................................. 14 RESULTS OF ATHROPOMETRICS SURVEY.........................................................................................15 1. Distribution by age and sex .......................................................................................................... 15 2. Anthropometric analysis ................................................................................................................ 16 2.1. Acute malnutrition ........................................................................................................................... 16 2.2. Risk of mortality: children’s muac................................................................................................ 20 3. Measles vaccination coverage................................................................................................... 20 4. Household status .............................................................................................................................. 21 5. Composition of the household .................................................................................................... 21 RESULTS OF RETROSPECTIVE MORTALITY SURVEY .........................................................................21 CONCLUSION....................................................................................................................................22 Appendix 2. Anthropometric survey questionnaire ........................................................................ 24 Appendix 3. Calendar of events Mvolo Payam – August, 2005 ................................................. 26 Appendix 4. Mortality survey questionnaire (Cluster enumeration data collection form). . 27

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Appendix 5. Mortality survey questionnaire form (Household enumeration data collection form for a death rate calculation survey). ........................................................................................ 28 Appendix 6. Anthropometric Survey questionnaire for children less than six months........... 29

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ACKNOWLEDGEMENTS ACF-USA acknowledges the invaluable support and assistance of the following:

OFDA for funding the survey,

Sudan Relief and Rehabilitation Commission (SRRC), both in Lokichoggio for facilitating the work in the field,

SUVAD for availing two of their staff to participate in the capacity building

program,

The local survey teams for working tirelessly, Mothers and caretakers, local authorities, and community leaders for their

co-operation.

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EXECUTIVE SUMMARY

INTRODUCTION Mvolo County in Western Equatoria Region, borders Rumbek County to the north, Yirol County to the north east, Mundri County to the south and Yambio and Tambura counties to the west. It is comprised of five payams namely: Mvolo, Bogori, Bhar el Grindi, Yeri and Lessi which are further subdivided into villages. The area is generally flat and characterized by rich savannah grassland with fertile alluvial soil. Rivers Mvolo and Yei provide water, grazing areas and fishing points in the area. The WFP interagency rapid needs assessment in Mvolo County reported that the poor rains in 2004 reduced harvest yields of most crops; the low flooding also resulted to low fish availability. Wild fruits which are normally the coping mechanism of the community during dry season had also become scarce. In 2005, the conflict between Dinka Agar and Dinka Atout around Mvolo/Yirol west border led to localized looting of food stocks which accordingly exacerbated the problem further. It was likewise reported that there were observable signs of malnutrition in children of IDP and returnee households and poorer resident households. From 24th August to 9th September, ACF-USA carried out a nutritional survey in Mvolo payam with the following objectives: To evaluate the nutritional status of children aged 6 to 59 months To estimate the measles immunisation coverage of children aged 9 to 59 months To identify groups at higher risk to malnutrition: age group and sex. To estimate the crude mortality rate through a retrospective survey.

METHODOLOGY Based on the reported SRRC population figure (24,100), a two-stage cluster sampling survey methodology had been initially planned for. However, the population seen on ground was less, and an exhaustive survey which covered all the villages in Mvolo payam was instead employed. A retrospective mortality survey following the SMART methodology (over the past three months) was simultaneously conducted with the anthropometric survey. Focus group discussions and observations were also done to capture food security and health information. SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATION

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The population of Mvolo payam mostly belongs to the Jur-bel tribe while minority is Dinka. The population are agro-pastoralists but farming is more predominant. Norwegian People’s Aid (NPA), Save the Children Foundation-USA (SCF-USA) and Sudan Inland Development Foundation (SIDF, an indigenous NGO) are the agencies on ground: NPA implements food security programs in the area while SCF-USA supports health services through the SIDF, with one Primary Health Care Centre (PHCC) and one Primary Health Care Unit (PHCU) delivering curative as well as preventive health care. The PHCC is located within Mvolo town while the PHCU is in Domeri village. There are six functional boreholes serving the whole payam; these are inaccessible to majority of families. For most parts of the year, water is sourced from seasonal streams and waterholes, while boreholes are depended on during the dry season. The use of latrines is not commonly practiced apart from those living within the town and in the NGO compounds. Lack of tools and equipment for digging latrines were expressed by the community as the constraint. Food at the household level was observed to be available and access to an assortment of green vegetables was seen. The community reports that the sorghum and maize stocks had been depleted and they have been surviving on cassava flour from the market, on pumpkins and on wild foods. The payam also receives food aid from WFP; the last distribution was in July this year whereby sorghum, oil and salt were distributed. A total of 663 children were measured during the nutritional survey; two records were eventually excluded from the analysis because of incoherent data. The result of the anthropometrics survey, are presented in the table below:

AGE GROUP INDICATOR RESULTS1

Global Acute Malnutrition W/H< -2 z and/or oedema 8.0%

Z-score Severe Acute Malnutrition W/H < -3 z and/or oedema 1.1%

Global Acute Malnutrition W/H < 80% and/or oedema 5.6%

6-59 months (n = 661) % Median

Severe Acute Malnutrition W/H < 70% and/or oedema 0.5%

Global Acute Malnutrition W/H < -2 z and/or oedema 13.1%

Z-score Severe Acute Malnutrition W/H < -3 z and/or oedema 2.1%

Global Acute Malnutrition W/H <80% and/or oedema 9.3%

6-29 months (n = 291)

% Median Severe Acute Malnutrition W/H <70% and/or oedema 0.7%

1 No confidence interval as exhaustive survey methodology was employed.

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Total crude retrospective mortality (last 3 months) /10,000/day Under five crude retrospective mortality /10,000/day Percentage of children under five amongst death recorded

0.47 [0.04 – 0.90] 0.0

0.0%

Measles immunization coverage

By card According to caretaker2 Not immunized

8.4% 44.6 % 47.1%

The results of the nutrition survey revealed that the nutritional situation in Mvolo County is not alarming. The rates detected by the survey were 8.0% of Global Acute Malnutrition (GAM) and 1.1% of Severe Acute Malnutrition (SAM) expressed in Z-scores; these rates are below the nutritional emergency threshold for south Sudan. The crude mortality rate is also within a non-critical level of 0.47/10,000/day. To enhance and sustain the current nutritional status of Mvolo community, some factors need to be put into consideration. The recommendations proposed by ACF-USA at this point are:

• SCF-USA and/or other health agencies to maintain and enhance coverage of primary health services in the county and ensure full implementation of the primary health care package, including EPI, health education as well as nutritional monitoring.

• Sanitation education and programs should be enhanced, including increasing

access to safe water and latrine facilities.

2 When no EPI card was available for the child at the household, measles vaccination information was collected according to the caretaker

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INTRODUCTION Mvolo County in Western Equatoria Region borders Rumbek County to the north, Yirol County to the North East, Mundri County to the South and Yambio and Tambura counties to the West. The County comprises of five payams namely: Mvolo, Bogori, Bhar el Grindi, Yeri and Lessi which are further subdivided into villages. The area is generally flat and characterized by rich savannah grassland with fertile alluvial soil. Rivers Mvolo and Yei provide water, grazing areas and fishing points in the county. The total population of the payam is estimated at 24,1003, who are mainly agro-pastoralists belonging to the Jur-bel tribe with a minority of Dinkas. The county has not witnessed any insecurity incident in the recent past. The last insecurity incident took place in the late 90s but since then, there has been prevailing peace. According to WFP interagency rapid needs report of Mvolo County, the poor rainy season of year 2004 reduced harvest of most crops and the low flooding resulted to limited fish availability and scarce supply of wild fruits which are normally the coping mechanism of the community during dry season. In March 2005, conflict between Dinka Agar and Dinka Atout around Mvolo/Yirol west border occurred and localized looting of food stocks within Mvolo accordingly exacerbated household food security further. Observable signs of malnutrition in children of IDP and returnee households and poorer resident households were also reported by the agencies on ground. A nutritional survey was then carried out by ACF-USA in Mvolo payam from 24th August to 9th September 2005 with the following objectives: To evaluate the nutritional status of children aged 6 to 59 months To estimate the measles immunisation coverage of children aged 9 to 59 months To identify groups at higher risk to malnutrition: age group and sex. To estimate the crude mortality rate through a retrospective survey.

METHODOLOGY

1. Type of Survey and Sample Size According to SRRC, population figures were estimated at 24,100 persons hence the number of children under five years was estimated at 4,820 (20% of the entire population). A two-stage cluster sampling survey methodology had been initially planned for; however, the presented population figure was not seen and an exhaustive survey which covered all the villages in Mvolo payam was instead employed. A total of 663 children were included for the anthropometrics survey. 3 SRRC records

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A retrospective mortality survey (over the past three months) was also conducted, alongside the anthropometric survey. Focus group discussions and observations were also done to capture food security and health information.

2. Sampling Methodology An exhaustive survey was conducted, meaning that all the children aged 6-59 months encountered in the villages of Mvolo payam were included in the survey. A household was defined by a mother and her children.

3. Data Collection During the anthropometric survey, for each selected child aged 6 to 59 months, the following information was recorded (See appendix 2 for the anthropometric questionnaire):

♦ Age: recorded with the help of a local calendar of events (See appendix 3 for the calendar of events)

♦ Gender: male or female ♦ Weight: children were weighed without clothes, with a SALTER weighing scale of 25

kg (precision of 100g). ♦ Height: children were measured on a measuring board (precision of 0.1 cm).

Children less than 85 cm were measured lying down, while those greater than or equal to 85 cm were measured standing up.

♦ Mid-Upper Arm Circumference: MUAC was measured at mid-point of left upper arm for measured children (precision of 0.1 cm).

♦ Bilateral oedema: assessed by the application of normal thumb pressure for at least 3 seconds to both feet.

♦ Measles vaccination: assessed by checking for measles vaccination on EPI cards and asking caretakers.

♦ Household status: for the surveyed children, households were asked if they were permanent residents, temporarily in the area, displaced or returnees.

During the retrospective mortality survey, in all the visited households – including where there were no children aged less than five years old – the teams asked for the number of household members alive per age groups, the number of people present within the recall period, the number of deaths and births over the last three months and the number of persons who left or arrived in the last three months (See appendices 4 and 5 for the mortality questionnaires- enumeration data collection forms for households and clusters).

4. Indicators, Guidelines and Formulas Used

4.1. Acute Malnutrition

• Weight-for-Height Index For the children, acute malnutrition rates were estimated from the weight for height (WFH) index values combined with the presence of oedema. The WFH indices are

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compared with NCHS4 references. WFH indices were expressed both in Z-scores and percentage of the median. The expression in Z-scores has true statistical meaning and allows inter-study comparison. The percentage of the median on the other hand is commonly used to identify eligible children for feeding programs. Guidelines for the results expressed in Z-scores: • Severe malnutrition is defined by WFH < -3 SD and/or existing bilateral oedema on the

lower limbs of the child • Moderate malnutrition is defined by WFH < -2 SD and ≥ -3 SD and no oedema. • Global acute malnutrition is defined by WFH < -2 SD and/or existing bilateral oedema Guidelines for the results expressed in percentage according to the median of reference: • Severe malnutrition is defined by WFH < 70 % and/or existing bilateral oedema on the

lower limbs • Moderate malnutrition is defined by WFH < 80 % and ≥ 70 % and no oedema. • Global acute malnutrition is defined by WFH <80% and/or existing bilateral oedema

• Children’s Mid-Upper Arm Circumference (MUAC) The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. The MUAC is only taken for children with a height of 75 cm and more. The guidelines are as follows: MUAC < 110 mm severe malnutrition and high risk of mortality MUAC ≥ 110 mm and <120 mm moderate malnutrition and moderate risk of mortality MUAC ≥ 120 mm and <125 mm high risk of malnutrition ,MUAC ≥ 125 mm and <135 mm moderate risk of malnutrition MUAC ≥ 135 mm ‘adequate’ nutritional status

4.2. Mortality The crude mortality rate (CMR) is determined for the entire population surveyed for a given period. The formula used for calculating the CMR according to ENA software is as follows: CMR = 10,000/a*f/ (b+f/2-e/2+d/2-c/2) Where: a = Number of recall days (period corresponds to 3 months (90 days) preceding the survey) b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during the recall period 4 NCHS: National Center for Health Statistics (1977) NCHS growth curves for children birth-18 years. United States. Vital Health Statistics. 165, 11-74.

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f = Number of deaths during recall period . Therefore, CMR is expressed per 10,000-people / day. The thresholds are defined as follows5: Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day The proportion of deaths within the past three months among the under five years old is also calculated.

5. Field work All the surveyors participating in the survey underwent a three-day training, which included a pilot survey. Four teams of four surveyors each executed the fieldwork. ACF-USA staff supervised all the teams in the villages. Accessibility to the whole county was limited since the team was not able to get a vehicle while on ground. Due to this, the sampling frame only included Mvolo payam whereby all the villages within the payam were surveyed. The survey, including the training and traveling days, lasted for a period of 17 days.

6. Data analysis Data processing and analysis were carried out using EPI-INFO 5.0 software and EPINUT 2.2 program. Mortality data was processed and analyzed using the Nutrisurvey for SMART software.

RESULTS of QUALITATIVE ASSESSMENT

1. Internally Displaced Persons (IDPs) and Returnees Population SRRC estimated that 1,282 returnees had arrived in the location between January and August, 2005. Additionally, 1,239 IDPs were recorded in the payam. Both the returnees and IDPs are arriving from different regions such as Maridi, Mundri, Juba, Yirol, Rumbek, Yambio, Wau, Uganda and Zaire.

5 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95.

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2. Food Security Tribes within Mvolo payam are predominantly agriculturalists rather than pastoralists. The main crops grown in the area include: sorghum, maize, simsim, groundnuts, green grams, beans, millet, sweet potatoes, pumpkins, yams and cassava. Vegetables like okra and cowpeas leaves are also major crops in the location and contribute significantly to the food economy of poor house holds. In most cases, cassava is grown to supplement other foods especially during the hunger gap. The area has two cropping seasons, from April to May and from July to September. The community’s diet mainly consists of sorghum. Cowpeas leaves, okra and pumpkin leaves accompany the sorghum/cassava diet depending on their availability. During the “hunger gap” period between July and September, the community depends on wild foods which contribute a significant amount to the food basket especially of the poor socio-economic group. The common wild foods are lulu (produces oil) and coconut tree (produces palm oil). Lulu oil is available through out the year while palm oil is available in July and August. Other wild foods include wild fruits like manga, buloto and tamarind gathered during the dry season and leaves like maribolo, collected at the beginning of the rains. Roots and tubers for example kanunu are also gathered, but this is determined by the availability of other foods. They are bitter and difficult to collect hence most people prefer growing their own vegetables for consumption and sale. In general, Mvolo has been on an upward economic and development trend for some time due to normally favourable rainfall (in terms of intensity and distribution) and availability of local seeds which has in turn resulted to consistency in improved crop performance. Although often a surplus area, the community reported that this year’s harvest was generally poor as a result of last season’s erratic rains as well as pests, birds and red baboons which destroyed maturing crops in the fields. In villages like Dotiraba and Medikanun, performance of this year’s harvest was more affected due to lack of rains. The community’s coping mechanism has currently been reduced as there are no assets like cattle that can be consumed or exchanged for grain. Fish contributes to the household food security, particularly for the poor and middle socio-economic groups. Fishing season starts in August and ends in December. This is carried out in Mvolo and Yei rivers and a seasonal stream-Talapari. Apart from being a major component of the household diet, fish is also sold in exchange for or to purchase household items. Livestock kept by the community include cattle, sheep, goat, pigeons, ducks and chicken. Cattle, kept by very few people in the community are a source of milk, for trading purposes and payment of dowry. At the time of the survey, the community reported that there was enough pasture for livestock since it was during the rainy season. Cattle, goats and sheep are not moved to graze far from homesteads during the dry season; instead they are grazed along river Mvolo and Talapari, a seasonal stream. OXFAM and FAO are supporting veterinary services in the payam; OXFAM provides drugs while FAO provides vaccines. There are community animal health workers (n=8) trained on livestock and poultry disease control through vaccination and treatment of livestock

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diseases. Services given to livestock owners in the community by the veterinary department are on a cost recovery basis. The common diseases of livestock reported by the veterinary personnel include: caprine contagious pleural pneumonia, foot and mouth disease, new castle disease, coccidiosis, black water disease, trypanosomiasis, contagious bovine plural pneumonia, east coast fever and worms. Trade takes place among the local residents, as well in regional and external markets. Major regional markets are in Yei, Lasu, Mundri, Yambio, Kotobi and Tambura while the external ones are found in Koboko, Arua in Uganda, Barpakey and Yirol. In both the regional and external markets, cassava, maize, groundnuts, sorghum, sesame, coffee, tea and tobacco are the main cash crops transacted. This has therefore ensured that the community has access to diversified food stuffs both internally and externally, and these are utilized by families.

3. Feeding and Childcare Practices Interviewed mothers revealed that weaning of most children started at the age of six months with millet/cassava porridge, pumpkin leaves soup/fish soup and honey mixed with water. Cow’s milk was not always available in most of the households as cattle keeping is not practiced widely in this location. Pregnant and lactating mothers continue to do heavy workload, and do not receive special diets and antenatal care. Rather, they are responsible for most of the household chores, compromising the time and care for their infants and consequently affecting the nutritional condition of the children who are mostly only fed when they cry. All household members consume one meal per day regardless of the age and eat together from a common bowl. This practice leads to competition for food, where the young and weak have lesser access to food. This in turn, compromises the caloric intake which is supposed to be between 1,150 kcal/day to 1,350 kcal/day for the children aged 11 – 59 months6

4. Health SCF-USA is the only agency providing health care in the payam. They are operating one PHCC and one PHCU in Mvolo town and Domeri village respectively. The health facilities offer preventive and curative health services. The PHCC is managed by a nurse, CHW and a lab technician while the PHCU is staffed by a CHW and maternal and child health worker. There are no EPI services in the payam; AAH who used to extend its immunization services from Mundri withdrew from the area. Most common ailments among the community are malaria, diarrhoea, eye infections, respiratory infections and river blindness which concurs with what has been documented by Starbase 2004. Other causes of morbidity are TB, epilepsy, onchocerciasis (OV), leprosy and hernia as reported by the county health department personnel. 5. Water and Sanitation There are seven water points in the payam of which six are operational; the boreholes are maintained by one pump mechanic who has been trained by UNICEF. The long 6 Assessment and Treatment of Malnutrition in Emergency Situations, 2002

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distance to the boreholes, for majority of the population however limits access, and water is sourced from streams and pools of collected water for all household needs. During the dry season, most families move near the banks of river Mvolo so as to access water easily while the rest depend on the few boreholes available. Treatment or boiling of drinking water is not practiced. Proportion of the population with access to improved sanitation in the payam is relatively low. Use of latrines is not common except for those living within the town and in the NGO compounds. The community is receptive to the idea of latrine use but very few were observed in the villages during the survey. The reason given for this was lack of tools and equipments to dig the latrines. There are nine (9) hygiene promoters in the payam trained by UNICEF and Oxfam who carry out sensitization workshops on basic hygiene education including latrine use.

6. Education There are 3 primary schools in the payam (offering levels 1-6 education) and 3 nursery schools; no secondary or tertiary levels of education are offered. Education is supported by UNICEF and ADRA who make provisions for learning materials on a yearly basis while SIDF, a local NGO is involved with construction activities through support from SCF-USA. The total number of pupils enrolled at the primary level is 1,761 of which 469 are girls and 1292 are boys with 7 trained and 10 untrained teachers/educators all working on voluntary basis. Lack of investment in the education sector and poor infrastructure in the Payam has contributed to low education rates in the community. Table 2: Distribution of primary and nursery schools and number teachers in the Payam

Village No. of primary schools

No. of nursery schools

No. of trained teachers

Number of untrained teachers

Dotiraba 1 - 3 3 Mvolo 1 1 7 5 Domeri 1 - 1 3 Kila - 1 2 2 Minikolome - 1 1 2

7. Agencies Intervening in the Area The humanitarian agencies operating in Mvolo are implementing programs on health, education and food security as outlined below. Table 3: Organizations intervening in Mvolo Payam

Agency Activities SCF-USA • Health: 1 PHCC and 1 PHCU NPA • Food security

SIDF • Health and education activities with technical support from SCF-USA

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ADRA • Education UNICEF • Education

RESULTS of ANTHROPOMETRICS SURVEY

A total of 663 children were measured but 661 records were included in the analysis due to aberrant data in 2 records.

1. Distribution by Age And Sex

Table 4: Distribution of the sample by age and sex BOYS GIRLS TOTAL AGE

(In months) N % N % N % Sex

Ratio 06 – 17 73 51.8% 68 48.2% 141 21.3% 1.07 18 – 29 80 53.3% 70 46.7% 150 22.7% 1.14 30 – 41 72 49.7% 73 50.3% 145 21.9% 0.99 42 – 53 75 62.5% 45 37.5% 120 18.2% 1.67 54 – 59 57 54.3% 48 45.7% 105 15.9% 1.19 Total 357 54.0% 304 46.0% 661 100.0% 1.17

The distribution of the sample by gender shows that boys are slightly more than girls. However, the sex ratio which is 1.17 indicates a random selection of the sample.

Figure 1: Distribution of the sample by age and sex, Mvolo Payam

-60% -40% -20% 0% 20% 40% 60% 80%

Percentage

06-17

18-29

30-41

42-53

54-59

Age

in m

onth

s

Distribution by age and sex, Mvolo payam, September 2005

BoysGirls

The results show a slight imbalance in age distribution having an over representation of boys in age group 42-53 months. This may be attributed to ages approximated by

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parents (caretakers) which are subject to recall bias; dates of birth were not known and a local calendar of events had to be used to estimate the ages.

2. Anthropometric Analysis

2.1. Acute malnutrition

♦ Distribution of malnutrition in Z-scores for children aged 6 to 59 months The distribution of acute malnutrition in Z-scores shows that the global acute malnutrition is equal to 8.0% with 1.1% of the children being severely malnourished and 7.0% moderately malnourished. Table 5: Weight for Height Distribution by age in Z-scores

Severe Malnutrition

Moderate malnutrition

No malnutrition AGE

(in months) Total < -3 SD

N % ≥-3 SD - <- 2

SD ≥ -2 SD

N %

Oedema N %

06-17 141 3 2.1% 21 14.9% 117 83.0% 0 0.0% 18-29 150 2 1.3% 11 7.3% 136 90.7% 1 0.7% 30-41 145 0 0.0% 5 3.4% 140 96.6% 0 0.0% 42-53 120 0 0.0% 3 2.5% 117 97.5% 0 0.0% 54-59 105 1 1.0% 6 5.7% 98 93.3% 0 0.0% TOTAL 661 6 0.9% 46 7.0% 608 92.0% 1 0.2%

Table 6: Weight for Height vs. oedema in Z-score

< -2 SD ≥ -2 SD

YES Marasmus/Kwashiork

or 0 0.0%

Kwashiorkor 1 0.2% Oedema

NO Marasmus 52 7.9%

No malnutrition 608 92.0%

One case of oedema – Kwashiorkor was found in the sample. All the other cases of malnutrition are of the marasmic type.

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Figure 2: Z-scores distribution Weight-for-Height, Mvolo payam

Weight for Height Z-score distribution, Mvolo payam, 2005

0

5

10

15

20

25

-5 -4 -3 -2 -1 0 1 2 3 4 5

Z-score

Perc

enta

ge

ReferenceSex Combined

There is minimal displacement of the sample curve to the left side of the reference curve. The mean Z-Scores of the sample, – 0.71, indicates a slightly under-nourished population. The standard deviation is equal to 0.93, which is in the range of 0.80 – 1.20. Therefore, the sample can be estimated as representative of the assessed population. Table 7: Global and Severe Acute Malnutrition by Age Group in Z-scores

6-59 months (n = 661) 6-29 months (n =291) Global acute malnutrition 8.0% 13.1% Severe acute malnutrition 1.1% 2.1%

There is a significant statistical difference between the malnutrition rates observed among the children of 6-29 months and the children aged 30-59 months (p < 0.05, Chi square test). Children aged 6-29 months present 3.22 [1.81<RR<5.74] more risk of being malnourished than the children of 30-59 months. Table 8: Nutritional Status in Z-scores by gender

Boys Girls Nutritional status Definition N % N %

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Severe malnutrition Weight for Height < -3 SD or oedema 6 1.7 1 0.3

Moderate malnutrition -3 SD ≤ Weight for Height < -2 SD 30 8.4 16 5.3

Normal Weight for Height ≥ -2 SD 321 89.9 287 94.4

TOTAL 357 100% 304 100

% The difference of figures observed between boys and girls is statistically significant (p<0.05, Chi square test). Boys are 1.80 times at risk of being malnourished as compared to girls CI= (1.03<RR<3.14).

♦ Distribution of malnutrition in % of the median for children aged 6 to 59 months

Acute malnutrition rates expressed in percentage of the median are useful in the coverage targeting for nutritional treatment programs and are used in its admission and exit criteria. The distribution of acute malnutrition in percentage of the median reveals a global acute malnutrition rate of 5.6%. 0.5% of the children were severely malnourished while 5.1% were moderately malnourished.

Table 9: Weight/Height: Distribution by Age in percentage of median Severe

malnutrition Moderate

malnutrition No

malnutrition AGE (In months) Total

< 70% N %

≥ 70% & <80%

≥ 80% N %

Oedema N %

06-17 141 1 0.7% 15 10.6% 125 88.7% 0 0.0% 18-29 150 0 0.0% 10 6.7% 139 92.7% 1 0.7% 30-41 145 0 0.0% 4 2.8% 141 97.2% 0 0.0% 42-53 120 0 0.0% 1 0.8% 119 99.2% 0 0.0% 54-59 105 1 1.0% 4 3.8% 100 95.2% 0 0.0% TOTAL 661 2 0.3% 34 5.1% 624 94.4% 1 0.2%

Table 10: Weight for Height vs. oedema in percentage of median

< -2 SD ≥ -2 SD

YES Marasmus/Kwashiork

or 0 0.0%

Kwashiorkor 1 0.2% Oedema

NO Marasmus 36 5.4%

No malnutrition 624 94.4%

One case of oedema – Kwashiorkor was found in the sample.

Table 11: Global and Severe Acute Malnutrition by Age Group in Percentage of Median

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6-59 months (n = 661) 6-29 months (n = 291) Acute global malnutrition 5.6% 9.3%

Severe acute malnutrition 0.5% 0.7%

According to the weight for height in percentage of median there is a significant difference in the nutritional status between the age groups 6-29 months and 30-59 months (p<0.05) with a relative risk of 3.43 (1.69<RR<6.98). Children of age group 6-29 months are 3.43 times more at risk of being malnourished than those of age group 30-59 months.

♦ Nutritional status of the children below six months 43 children aged below six months, present in the households at the time of the survey, were measured in order to determine their nutritional status. 26 (60.5%) were boys and 17 (39.5%) were girls.

Table 12: Age distribution of the under six months

Age in month N % 0 - - 1 14 32.6% 2 8 18.6% 3 5 11.6% 4 6 14.0% 5 10 23.3%

Total 43 100% In both the Z score and percentage of median analysis of the 43 children, only 39 children were included. This was because some caretakers did not accept their infants to be taken the weight and height measurements. According to the Weight for Height index in Z-score and in percentage of median, there was no acute malnutrition recorded among the under-six months children measured. All the infants were of good nutritional status.

• Feeding practices Three-quarters of the mothers who had children less than six months breastfed exclusively 40 (93.0%) while only 1 (2.3%) had begun weaning. 2 (4.7%) mothers were practicing mixed feeding. The weaning food was mainly composed of pumpkin leaves/fish soup, honey mixed with water and millet/cassava porridge.

Table 13: Feeding practices

Feeding practices Frequency Percentage

Exclusive breastfeeding 40 93.0%

20

Mixed feeding (breast milk and weaning food)

2 4.7%

Exclusive weaning 1 2.3% Total 43 100%

2.2. Risk of mortality: children’s MUAC As MUAC overestimates the level of under nutrition in children less than one year old, the analysis refers only to children having height equal to or greater than 75 cm. A total of 555 children have been included in the analysis. Table 14: Nutritional Status by MUAC.

Total 75 – 90 cm height

≥ 90 cm height Criteria Nutritional status

N % N % N % < 110 mm Severe malnutrition 1 0.2 1 0.4 0 0.0

110 mm ≥ MUAC < 120 Moderate 8 1.4 4 1.5 4 1.4 120 mm ≥ MUAC < 135 At risk of 89 16.0 68 25.9 21 7.2

MUAC ≥ 135 mm No malnutrition 457 82.3 190 72.2 267 91.4 TOTAL 555 100.0 263 100.0 292 100.0

By MUAC measurements, 82.3% showed good nutritional status while 1.4% was moderately malnourished and 16.0% were at risk. There were more children within the 75-90 cm height group at risk of malnutrition as compared to those of >90cm height group.

3. Measles Vaccination Coverage Measles vaccination for the regular EPI is administered to children aged 9 months; therefore only the children aged 9-59 months (646 children) were included in this analysis. Table 15: Measles vaccination coverage

Measles Vaccination N %

EPI card 54 8.4

According to the caretaker 288 44.6

Not immunized 304 47.1

Total 646 100 Measles vaccination of 8.4% of the children was confirmed by the presence of EPI cards, while caretakers affirm vaccination in the other 44.6% of the children although no card was produced. The remaining 47.1% had not received measles vaccination.

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4. Household Status The information on the residential status was collected from 417 caretakers during the anthropometric survey.

Table 16: Household status Status N %

Residents 404 96.9

Returnees 2 0.5

Temporarily residents 11 2.6

Total 417 100 Four hundred and seventeen households were visited during the survey. The larger proportion of the surveyed families was residents 404 (96.9%) while 2 (0.5%) were returnees. 11 (2.6%) of the households were temporarily residing in the location. The results revealed minimal movement of the population during the survey period.

5. Composition of the Household

Table 17: Household composition Age group N %

0 to 59 months 714 33.9 Adults 1,389 66.1 Total 2,103 100.0

426 households were visited during the survey. The mean number of under-five per household is 1.7 and the mean number of the over five per household is 3.3.

RESULTS of RETROSPECTIVE MORTALITY SURVEY

1. Mortality Rate The crude mortality was calculated from the figures collected from all visited households, regardless of whether there were under-five children. During the survey, a total of 2,103 people were found in the assessed households. Among them were 714 children below the age of five years alive (33.3% of the total population), as well as 1,389 people above the age of five years.

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Over the three months preceding the survey, the following demographic changes were observed:

♦ 29 births ♦ 58 persons had arrived in the location ♦ And 144 people had left the location in the same period ♦ 9 deaths, no children below the age five years old were recorded.

Crude Mortality Rate (CMR)/10,000/day = 0.47[0.04-0.90] Under five Crude Mortality Rate /10,000/day =0.00 According to the above formula, the crude mortality rate is 0.47/10,000/day.

CONCLUSION

The nutritional survey was undertaken in one of the five payams of Mvolo County, sampling 661 children aged 6-59 months. The analysis of the anthropometrics data showed that 8.0% of the children are acutely malnourished of which 1.1% is severely malnourished. Among children 6-29 months, the GAM rate is 12.4% while SAM is 1.5%. These rates indicate an acceptable nutritional status among the population in the payam. In general, Mvolo has been on an upward economic and development trend due to normally favourable rainfall (in terms of intensity and distribution) and availability of local seeds which has in turn resulted to consistency in improved crop performance. Diversified food is available and accessible both internally and externally through the regional and external markets. Vegetables like okra and cowpeas leaves are also major crops in the location and contribute significantly to the food economy of poor house holds. Fish contributes to the household food security, especially of the poor and middle socio-economic groups and some are also being sold in exchange for or to purchase household items. Additionally, the most vulnerable people in the community are currently being cushioned from food insecurity by WFP through food rations. To enhance and sustain the current nutritional status of Mvolo community, some factors need to be put into consideration. The recommendations proposed by ACF-USA at this point are:

• SCF-USA and/or other health agencies to maintain and enhance coverage of primary health services in the county and ensure full implementation of the primary health care package, including EPI, health education as well as nutritional monitoring.

• Sanitation education and programs should be enhanced, including increasing

access to safe water and latrine facilities.

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Appendix 1. List of Villages and estimated distances Villages Estimated distances from

Mvolo town Estimated Total

Population Target population (20% of the entire population)

Mvolo 2hrs 305 61 Medikanun 3hrs 285 57 Minikolome 2hrs 30mins 150 30 Ebebodo 3hrs 155 31 Modo 6hrs 155 31 Lessi 2hrs 150 30 Mering 6hrs 160 32 Muke 3hrs 30mins 155 31 Miyalla 8hrs 460 92 Ebedomomi 3hrs 155 31 Domeri 6 hrs 250 50 Dotiraba 3hrs 180 36 Kila 8hrs 450 90 Zeri 3hrs 30mins 155 31 Benyikori 3hrs 150 30 Total 3315 663* The total Target population was less than 1,000 hence exhaustive methodology was used.

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Appendix 2. Anthropometric survey questionnaire DATE: CLUSTER No: VILLAGE: TEAM No:

N°. Family N°.

Status (1)

Age Mths

Gender M/F

Weight Kg

Height Cm

Sitting Height Cm(2)

Oedema Y/N

MUAC

mm

Measles C/M/N

(3) 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

ANTHROPOMETRIC SURVEY QUESTIONNAIRE

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(1) Status: 1=Resident, 2=Displaced (because of fighting, length < 6 months), 3=Family temporarily resident in village (cattle camp, water point, visiting family…), 4=Returnee

(2) Sitting Height is optional. To apply for ACF-USA survey. This data is for research (3) Measles*: C=according to EPI card, M=according to mother, N=not immunized against

measles

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Appendix 3. Calendar of events Mvolo Payam – August, 2005 MONTHS SEASONS 2000 2001 2002 2003 2004 2005

55 43 31 19 7 JANUARY Shar wahid

Harvesting millet and renovating

Mvolo is made a County

54 42 30 18 6 FEBRUARY Hunting and

53 41 29 17 5 MARCH Shar talata

Land preparation, fishing and movement to water points

A soldier opens a grenade killing himself and hurting those around.

Conflict between Agar and Atout clans of Bhar el Ghazal which spilled into Mvolo leading to looting and cattle rustling. This continued up to May

52 40 28 16 4 APRIL Shar aruba

planting of maize, beans cassava

NPA starts operating in Mvolo

51 39 27 15 3 MAY planting simsim

50 38 26 14 2 JUNE Weeding and

49 37 25 13 1 JULY Start of hunger

48 36 24 12

AUGUST Harvesting of

47 35 23 11 SEPTEMBER Shar tisa

Harvesting groundnuts, beans and honey

59 Much fish in river

Mvolo that people from other counties came to do fishing.

46 34 Soldiers coming

f T it l t d

22 10 OCTOBER Shar ashra Harvesting

sorghum

58

rape women on their way to Bhar el ghazal

45 33 21 9 NOVEMBER Stocking of grains 57

44 32 20 8

DECEMBER Christmas 56

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Appendix 4. Mortality survey questionnaire (Cluster enumeration data collection form).

Survey Payam: Village: Cluster number: HH number: Date: Team number:

Current HH Member

Current HH members who arrived during

recall (exclude births)

Past HH members who left during

recall (exclude deaths)

Deaths during recall N

Total < 5 Total <5 Total < 5

Births during recall

Total < 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

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Appendix 5. Mortality survey questionnaire form (Household enumeration data collection form for a death rate calculation survey).

Survey Payam: Village: Cluster number: HH number: Date: Team number:

1 2 3 4 5 6 7

ID HH member

Present now

Present at beginning of recall (include those not present now and indicate which members were not present at the start of the

recall period )

Sex

Date of birth/or age in years

Born during recall

period?

Died during

the recall period

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20

Tally (these data are entered into Nutrisurvey for each household): Current HH members – total Current HH members - < 5 Current HH members who arrived during recall (exclude births)

Current HH members who arrived during recall - <5 Past HH members who left during recall (exclude deaths) Past HH members who left during recall - < 5 Births during recall Total deaths Deaths < 5

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Appendix 6. Anthropometric Survey questionnaire for children less than six months

DATE: CLUSTER No: VILLAGE: TEAM No:

N°. Family N°.

Age Mths

Sex M/F

Weight Kg

Height Cm

Feeding practices*

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

ANTHROPOMETRIC SURVEY QUESTIONNAIRE FOR CHILDREN LESS THAN 6 MONTHS

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* Exclusive breast-feeding= 1; mixed feeding (breast-milk and weaning food) =2; exclusive weaning food =3.